Can a Health Insurance Company Stop Paying Mid-Treatment?

By: Cohen, Placitella & Roth @ Jul 10, 2017

When you have a health condition that is serious enough that your wellbeing is at risk if you do not receive treatment, the idea of your insurance company denying your treatment is both shocking and threatening. However, that is exactly what happened for one Orange County man, 22-year-old Gillen Washington, who suffers from an immunodeficiency disease.

Insurance Company Denies Treatment

According to an article published in Medscape, Washington had been receiving medication for his immunodeficiency disease since 2011 when one day, when he arrived at his clinic for his regular dosage, the nurse told him that his insurance company had denied his treatment. When he inquired with his insurance company – Aetna – he was told that his blood work was outdated, and because of this, his blood work did not show that his treatment was a medical necessity.

As he waited for his lawyer to appeal Aetna’s decision, his health declined dramatically. He developed a cough, returning home to Huntington Beach where he then suffered from pneumonia and a collapsed lung. His lawyer filed a lawsuit against the insurance giant for a breach of contract. The case will be tried this June, 2017.

How Company Is it For Insurance Companies to Deny Care?

According to the same article cited above, Washington’s case may not be as unique as it would seem. In fact, patients with immunodeficiency diseases have had an increasingly more difficult time receiving the medication that they need, which can have a huge effect on patients’ outcomes. A professor of immunology at Duke University Medical Center, Dr. Rebecca Buckley, called an interruption in medication a “serious problem,” explaining that the consequences of stopped medication can be devastating. Unfortunately, many doctors who work for insurance companies – and make decisions about whether or not a medication is necessary – are not specialists. When a doctor does not specialize in a certain condition, and does not have an established relationship with the patient, it can be very difficult for that doctor to know what the patient really needs.

In Washington’s case, the good news is that he is back on the medication; in 2015, Aetna reapproved the medicine he needs for good health. Despite this, he has no doubt suffered physical and psychological harm as a result of the company’s original denial of his medicine, and explained that he cannot fathom how a doctor who has never seen him could deny him something he needs.

Your Right to Medical Care When You Need It

At the law offices of Cohen, Placitella & Roth, P.C., we believe that when you have a medical condition that requires treatment, you deserve the best of care. Whether you are denied what you need due to medical malpractice, defective pharmaceuticals, breach of contract, or other issues, our attorneys are here to review your case for free and guide you through the civil process if we believe that you have a case. To schedule a free consultation, reach us now by phone or online.